MEDICATION COVERAGE POLICY - Health Plan of San Joaquin
嚜燐EDICATION COVERAGE POLICY
PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE
POLICY
THERAPEUTIC CLASS
LOB AFFECTED
Thyroid Disorders
Endocrine Disorders
Medi-Cal
P&T DATE:
REVIEW HISTORY
( MONTH / YEAR )
12/08/2020
12/19,12/18, 9/17, 12/16,
11/15
This policy has been developed through review of medical literature, consideration of medical necessity, generally accepted medical
practice standards, and approved by the HPSJ Pharmacy and Therapeutic Advisory Committee.
? OVERVIEW
Treatment of hyperthyroidism and hypothyroidism is well-defined: methimazole and levothyroxine monotherapy are
the mainstays of treatment for hyperthyroidism and hypothyroidism, respectively.1,2 The purpose of this Thyroid
Disorders Coverage Policy is to review the coverage criteria of HPSJ*s formulary anti-thyroid and thyroid agents (Table
1).
Table 1: Available Anti-Thyroid & Thyroid Medications (Current as of 09/2020)
Generic Name or
Brand Name
Available Strengths
Formulary
Limits
Average
Cost per Rx
ANTI-THYROID MEDICATIONS
Methimazole
Propylthiouracil
5, 10 mg tablets
50 mg tablet
Armour Thyroid
Levothyroxine sodium
Levoxyl
Liothyronine sodium
NP Thyroid
Synthroid
Tirosint
WP Thyroid
15, 30, 60, 90, 120, 180, 240, 300 mg tablets
25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300 mcg tablets
25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200 mcg tablets
5, 25, 50 mcg tablets
48.75, 65, 81.25, 97.5, 113.75, 130, 146.25, 162.5, 195, 260, 325 mg
tablets
15, 30, 60, 90,120 mg tablets
25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300 mcg tablets
13, 25, 50, 75, 88, 100, 112, 125, 137, 150 mcg capsules
16.25, 32.5, 48.75, 65, 81.25, 97.5, 113.75, 130 mg tablets
Thyrogen
1.1 mg vial
-
$4.93
$33.30
NF
-
$39.52
$10.60
$32.58
$27.19
NF
$10.98
NF
NF
NF
$23.04
$43.01
$140.95
--
THYROID MEDICATIONS
Nature-Throid
THYROID FUNCTION DIAGNOSTIC AGENT
PA ; SP
$3,417.05
Bolded items = Brand name drug cost/utilization; PA = Prior Authorization Required; NF = Non-formulary; SP = Restricted to Specialty Pharmacy
? EVALUATION CRITERIA FOR APPROVAL/EXCEPTION CONSIDERATION
Below are the coverage criteria and required information for each agent. These coverage criteria have been reviewed &
approved by the HPSJ Pharmacy & Therapeutics (P&T) Advisory Committee. For conditions not covered under this
Coverage Policy, HPSJ will make the determination based on Medical Necessity as described in HPSJ Medical Review
Guidelines (UM06).
Anti-Thyroid Agents
Methimazole, Propylthiouracil
? Coverage Criteria: None
? Limits: None
? Required Information for Approval: N/A
? Other Notes: None
Thyroid Agents
Armour Thyroid, Levothyroxine sodium, Liothyronine sodium, NP Thyroid, Synthroid, Tirosint
Armour Thyroid, Levothyroxine sodium, Liothyronine sodium, NP Thyroid
? Coverage Criteria: None
? Limits: None
Coverage Policy 每 Endocrine Disorders 每 Thyroid Disorders
Page 1
? Required Information for Approval: N/A
? Other Notes: None
? Non-Formulary: Brand name Synthroid, Tirosint
Thyroid Agents
Thyrotropin alfa (Thyrogen)
? Coverage Criteria: Approval is determined by medical necessity criteria.
? Limits: None
? Required Information for Approval: N/A
? Other Notes: Medication is to be dispensed by HPSJ*s designated Specialty Pharmacy.
? CLINICAL JUSTIFICATION
Methimazole is recommended for the treatment of all patients with Graves* Disease (except during the first trimester of
pregnancy), in the treatment of thyroid storm, and in patients who refuse radioactive iodine therapy or surgery. 1
During the first trimester of pregnancy, propylthiouracil is preferred because it does not cross the placenta as readily,
whereas methimazole has been associated with rare birth defects.3 Levothyroxine monotherapy is the current
standard of care for treating hypothyroidism. Levothyroxine (synthetic T4) is preferred over T3 agents (desiccated
thyroid extracts and liothyronine) due to its long half-life and better gastrointestinal absorption.2
? REFERENCES
1.
2.
3.
Bahn RS, Burch HB, Cooper DS et al. Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines of the
American Thyroid Association and the American Association of Clinical Endocrinologists. Endocr Pract. 2011;17(3):456-520.
Garber JR, Cobin RH, Gharib H et al. Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American
Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988每1028.
Thyroid disease in pregnancy. Practice Bulletin No. 148. American College of Obstetricians and Gynecologists. Obstet Gynecol.
2015;125:996每1005.
? REVIEW & EDIT HISTORY
Document Changes
Creation of Policy
Update to Policy
Update to Policy
Update to Policy
Reference
HPSJ Coverage Policy 每 Endocrine Disorders 每 Thyroid
Disorders 2015-11.docx
HPSJ Coverage Policy - Endocrine Disorders - Thyroid
Disorders 2016-12.docx
HPSJ Coverage Policy - Endocrine Disorders - Thyroid
Disorders 2017-09.docx
HPSJ Coverage Policy 每 Endocrine 每 Thyroid Disorders
2018-12.docx
Thyroid Disorders
Date
11/2015
P&T Chairman
Johnathan Yeh, PharmD
12/2016
Johnathan Yeh, PharmD
9/2017
Johnathan Yeh, PharmD
Matthew Garrett,
PharmD
Review Policy
12/2019
Matthew Garrett,
PharmD
Review Policy
Thyroid Disorders
12/2020
Matthew Garrett,
PharmD
Note: All changes are approved by the HPSJ P&T Committee before incorporation into the utilization policy
Coverage Policy 每 Endocrine Disorders 每 Thyroid Disorders
12/2018
Page 2
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- about armour thyroid nhns
- armour thyroid usp and combined thyroxine tri iodothyronine as
- armour thyroid
- highlights of prescribing information dosage
- armour thyroid thyroid tablets usp rxabbvie
- armour thyroid thyroid tablets usp center for inquiry
- np thyroid thyroid tablets usp
- management of hypothyroidism in pregnancy with armour thyroid
- medication coverage policy health plan of san joaquin
- why np thyroid
Related searches
- meridian health plan of michigan careers
- meridian health plan illinois
- meridian health plan member portal
- meridian health plan illinois provider portal
- meridian health plan medicaid michigan
- meridian health plan michigan
- meridian health plan of michigan
- meridian health plan illinois medicaid
- meridian health plan appeal form
- meridian health plan illinois careers
- meridian health plan jobs
- allegiance health plan provider portal